Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BUSPIRONE TAB [15 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000543
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

BUSPIRONE TAB [15 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000543
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

BUSPIRONE TAB [5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000061
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

BUSPIRONE TAB [5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000061
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

C1 ESTERASE INHIBITOR (004648)

Facility

$68.00

Service Code	CPT 86160
Hospital Charge Code	4061601
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

C1 ESTERASE INHIBITOR (004648)

Facility

$68.00

Service Code	CPT 86160
Hospital Charge Code	4061601
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

C1 ESTERASE INHIBITOR FUNCTIONAL(120220)

Facility

$68.00

Service Code	CPT 86161
Hospital Charge Code	4086161
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

C1 ESTERASE INHIBITOR FUNCTIONAL(120220)

Facility

$68.00

Service Code	CPT 86161
Hospital Charge Code	4086161
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

C3 AND C4 COMPLEMENT

Facility

$150.00

Service Code	CPT 86160
Hospital Charge Code	4088058
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

C3 AND C4 COMPLEMENT

Facility

$150.00

Service Code	CPT 86160
Hospital Charge Code	4088058
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

CA 125 (002303)

Facility

$80.00

Service Code	CPT 86304
Hospital Charge Code	4086304
Hospital Revenue Code	300
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

CA 125 (002303)

Facility

$80.00

Service Code	CPT 86304
Hospital Charge Code	4086304
Hospital Revenue Code	300
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

CA 19-9 (002261)

Facility

$39.00

Service Code	CPT 86301
Hospital Charge Code	4086301
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

CA 19-9 (002261)

Facility

$39.00

Service Code	CPT 86301
Hospital Charge Code	4086301
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

CADEXOMER IODINE GEL [40 G]

Facility

$219.00

Service Code	HCPCS J3490
Hospital Charge Code	3000063
Hospital Revenue Code	250
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

CADEXOMER IODINE GEL [40 G]

Facility

$219.00

Service Code	HCPCS J3490
Hospital Charge Code	3000063
Hospital Revenue Code	250
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

CALCITONIN (004895)

Facility

$113.00

Service Code	CPT 82308
Hospital Charge Code	4082308
Hospital Revenue Code	301
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

CALCITONIN (004895)

Facility

$113.00

Service Code	CPT 82308
Hospital Charge Code	4082308
Hospital Revenue Code	301
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

CALCITONIN-SALMON NASAL SPRAY

Facility

$398.00

Service Code	HCPCS J3490
Hospital Charge Code	3000064
Hospital Revenue Code	259
Min. Negotiated Rate	$278.60
Max. Negotiated Rate	$398.00
Rate for Payer: Aetna Commercial	$378.10
Rate for Payer: Aetna Medicare	$358.20
Rate for Payer: BCBS MT CHIP	$358.20
Rate for Payer: BCBS MT Closed Plan Network	$378.10
Rate for Payer: BCBS MT HealthLink	$358.20
Rate for Payer: BCBS MT Medicare	$358.20
Rate for Payer: BCBS MT POS	$378.10
Rate for Payer: BCBS MT Traditional	$398.00
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cigna Commercial	$378.10
Rate for Payer: Cigna Medicare	$358.20
Rate for Payer: Medicaid All Medicaid	$366.16
Rate for Payer: Medicare All Medicare	$278.60
Rate for Payer: Monida Allegiance	$378.10
Rate for Payer: Monida First Choice Health	$386.06
Rate for Payer: Monida Montana Health Co-op	$378.10
Rate for Payer: Monida PacificSource	$378.10

CALCITONIN-SALMON NASAL SPRAY

Facility

$398.00

Service Code	HCPCS J3490
Hospital Charge Code	3000064
Hospital Revenue Code	259
Min. Negotiated Rate	$278.60
Max. Negotiated Rate	$398.00
Rate for Payer: Aetna Commercial	$378.10
Rate for Payer: Aetna Medicare	$358.20
Rate for Payer: BCBS MT CHIP	$358.20
Rate for Payer: BCBS MT Closed Plan Network	$378.10
Rate for Payer: BCBS MT HealthLink	$358.20
Rate for Payer: BCBS MT Medicare	$358.20
Rate for Payer: BCBS MT POS	$378.10
Rate for Payer: BCBS MT Traditional	$398.00
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cigna Commercial	$378.10
Rate for Payer: Cigna Medicare	$358.20
Rate for Payer: Medicaid All Medicaid	$366.16
Rate for Payer: Medicare All Medicare	$278.60
Rate for Payer: Monida Allegiance	$378.10
Rate for Payer: Monida First Choice Health	$386.06
Rate for Payer: Monida Montana Health Co-op	$378.10
Rate for Payer: Monida PacificSource	$378.10

CALCITRIOL TAB [0.25 MCG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007212
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

CALCITRIOL TAB [0.25 MCG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007212
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

CALCIUM, 24 HOUR URINE (003269)

Facility

$59.00

Service Code	CPT 82340
Hospital Charge Code	4082340
Hospital Revenue Code	300
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

CALCIUM, 24 HOUR URINE (003269)

Facility

$59.00

Service Code	CPT 82340
Hospital Charge Code	4082340
Hospital Revenue Code	300
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

CALCIUM CARB CHEW TAB [500 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000065
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

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